HIV treatment: Difference between revisions
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* See also [[HIV medications]] |
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==When to Start== |
==When to Start== |
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*Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia |
*Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia |
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**Decreased AIDS-related morbidity, non-AIDS-related morbidity, and mortality[[CiteRef::2015in]][[CiteRef::2015a]] |
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*Start as soon as possible in patients with acute HIV, as it decreases the HIV reservoir |
*Start as soon as possible in patients with acute HIV, as it decreases the HIV reservoir |
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**Less loss-to-follow-up, time-to-virologic-suppression decreased |
**Less loss-to-follow-up, time-to-virologic-suppression decreased |
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*Do not stop treatment |
*Do not stop treatment |
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*Unclear whether treatment needed for elite controllers |
*Unclear whether treatment needed for elite controllers |
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*Only delay treatment in |
*Only delay treatment in: |
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**[[Cryptococcal meningitis]], which should be delayed by 2 to 10 weeks |
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**[[Tuberculosis]] |
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***CD4 <50 cells/mL: start within 2 weeks |
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***CD4 ≥50 cells/mL: start within 8 weeks |
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***[[Tuberculous meningitis]]: start within 2 to 8 weeks |
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==Starting Treatment== |
==Starting Treatment== |
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*Refer to [[HIV medications]] for information about specific medications |
*Refer to [[HIV medications]] for information about specific medications |
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*In general, use two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor) |
*In general, use two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor) |
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**New evidence in favour of two-drug regimens that include an integrase inhibitor |
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*Preference for [[single-tablet regimens for HIV]], which improve adherence |
*Preference for [[single-tablet regimens for HIV]], which improve adherence |
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*Recommended first-line regimens include: |
*Recommended first-line regimens include: |
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**[[Dolutegravir]]/[[abacavir]]/[[lamivudine]] (Triumeq), only for individuals who are HLA-B*5701 negative and without chronic hepatitis B virus (HBV) coinfection |
**[[Dolutegravir]]/[[abacavir]]/[[lamivudine]] (Triumeq), only for individuals who are HLA-B*5701 negative and without chronic hepatitis B virus (HBV) coinfection |
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**[[Dolutegravir]] plus ([[emtricitabine]] or [[lamivudine]]) plus ([[tenofovir alafenamide]] or [[tenofovir disoproxil fumarate]]) |
**[[Dolutegravir]] plus ([[emtricitabine]] or [[lamivudine]]) plus ([[tenofovir alafenamide]] or [[tenofovir disoproxil fumarate]]) |
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**[[Dolutegravir]]/[[lamivudine]] (Dovato), except for individuals with HIV RNA >500,000 copies/mL, HBV co-infection, or in whom ART is to be started before the results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available |
**[[Dolutegravir]]/[[lamivudine]] (Dovato), except for individuals with HIV RNA >500,000 copies/mL, HBV co-infection, or in whom ART is to be started before the results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available |
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**[[Raltegravir]] plus ([[emtricitabine]] or [[lamivudine]]) plus ([[tenofovir alafenamide]] or [[tenofovir disoproxil fumarate]]) |
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==Special Populations== |
==Special Populations== |
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*NRTI backbone: [[abacavir]]/[[lamivudine]], [[tenofovir]]/[[emtricitabine]], or [[tenofovir]]/[[lamivudine]] |
*NRTI backbone: [[abacavir]]/[[lamivudine]], [[tenofovir]]/[[emtricitabine]], or [[tenofovir]]/[[lamivudine]] |
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*3rd agent |
*3rd agent |
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**[[Dolutegravir]] is preferred given preponderance of data |
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**Protease inhibitor: ATV/r or DRV/r |
**Protease inhibitor: ATV/r or DRV/r |
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*Avoid dolutegravir, may cause neural tube defects when on it at the time of conception (but not if started during pregnancy) |
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===Hepatitis B |
===Hepatitis B Coinfection=== |
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* |
*Regimen should contain [[tenofovir]] plus another HBV-active agent |
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*Ideally, use [[tenofovir]], [[lamivudine]] or [[emtricitabine]], and a third agent |
*Ideally, use [[tenofovir]], [[lamivudine]] or [[emtricitabine]], and a third agent |
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**[[Tenofovir]]/[[lamivudine]] + other |
**[[Tenofovir]]/[[lamivudine]] + other |
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**[[Tenofovir]]/[[emtricitabine]] + other |
**[[Tenofovir]]/[[emtricitabine]] + other |
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*If cannot use [[tenofovir]] (severe renal or hepatic dysfunction), then add [[entecavir]] to the HIV regimen |
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===Hepatitis C |
===Hepatitis C Coinfection=== |
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*See also [[HIV-Hepatitis C coinfection]] for details |
*See also [[HIV-Hepatitis C coinfection]] for details |
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*If using PI, [[rifabutin]] can be used instead of [[rifampin]] |
*If using PI, [[rifabutin]] can be used instead of [[rifampin]] |
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===Cryptococcal |
===Cryptococcal Meningitis=== |
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=== Patients with Feeding Tubes === |
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* Needs crushable or dissolvable medications |
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* Good pick is [[Truvada]] + [[raltegravir]] |
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* See also [https://www.hivclinic.ca/main/drugs_extra_files/Crushing%20and%20Liquid%20ARV%20Formulations.pdf HIVClinic.ca list of crushable and liquid formulations] |
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=== Chronic Kidney Disease === |
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* In general, try to avoid starting [[tenofovir disoproxil fumarate]] with eGFR <60 mL/min and [[TAF]] if <30 mL/Min; avoid [[ATV]] |
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* Can use TAF on hemodialysis |
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==Switching Regimens== |
==Switching Regimens== |
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Latest revision as of 02:07, 2 April 2023
- See also HIV medications
When to Start
- Start in all viremic patients regardless of CD4 count and in all patients with declining CD4 regardless of viremia
- Start as soon as possible in patients with acute HIV, as it decreases the HIV reservoir
- Less loss-to-follow-up, time-to-virologic-suppression decreased
- Rapid linkage to care within 5 working days of diagnosis
- Do not stop treatment
- Unclear whether treatment needed for elite controllers
- Only delay treatment in:
- Cryptococcal meningitis, which should be delayed by 2 to 10 weeks
- Tuberculosis
- CD4 <50 cells/mL: start within 2 weeks
- CD4 ≥50 cells/mL: start within 8 weeks
- Tuberculous meningitis: start within 2 to 8 weeks
Starting Treatment
- Arrange their first clinic visit, and do the appropriate investigations
- Choose an appropriate single-tablet regimens, and start
- Preference for regimen that includes integrase inhibitor
- Book follow-up
Antiretroviral Therapy (ART) Regimens
- Refer to HIV medications for information about specific medications
- In general, use two nucleoside reverse-transcriptase inhibitors (NRTIs) and one non-NRTI (usually an integrase inhibitor)
- New evidence in favour of two-drug regimens that include an integrase inhibitor
- Preference for single-tablet regimens for HIV, which improve adherence
- Recommended first-line regimens include:
- Bictegravir/tenofovir alafenamide/emtricitabine (Biktarvy)
- Dolutegravir/abacavir/lamivudine (Triumeq), only for individuals who are HLA-B*5701 negative and without chronic hepatitis B virus (HBV) coinfection
- Dolutegravir plus (emtricitabine or lamivudine) plus (tenofovir alafenamide or tenofovir disoproxil fumarate)
- Dolutegravir/lamivudine (Dovato), except for individuals with HIV RNA >500,000 copies/mL, HBV co-infection, or in whom ART is to be started before the results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available
Special Populations
Pregnancy
- Treat!
- NRTI backbone: abacavir/lamivudine, tenofovir/emtricitabine, or tenofovir/lamivudine
- 3rd agent
- Dolutegravir is preferred given preponderance of data
- Raltegravir
- Protease inhibitor: ATV/r or DRV/r
Hepatitis B Coinfection
- Regimen should contain tenofovir plus another HBV-active agent
- Ideally, use tenofovir, lamivudine or emtricitabine, and a third agent
- Tenofovir/lamivudine + other
- Tenofovir/emtricitabine + other
- If cannot use tenofovir (severe renal or hepatic dysfunction), then add entecavir to the HIV regimen
Hepatitis C Coinfection
- See also HIV-Hepatitis C coinfection for details
- In general, there's no need to delay either treatment; they can be treated concurrently
- Beware significant interactions with HCV medications
- Avoid elvitegravir/cobicistat whenever possible, as it interacts with most regimens
- Sofosbuvir can increase TDF (though not TAF) levels
Tuberculosis
- Probably don't need to wait to treat
- Avoid TAF if using rifampin/rifamycin
- If using rifampin
- Efavirenz probably the best option
- Raltegravir needs dose increase to 800 mg BID
- Dolutegravir 50 mg BID only without selected INSTI mutations
- If using PI, rifabutin can be used instead of rifampin
Cryptococcal Meningitis
- Delay treatment for risk of IRIS
Patients with Feeding Tubes
- Needs crushable or dissolvable medications
- Good pick is Truvada + raltegravir
- See also HIVClinic.ca list of crushable and liquid formulations
Chronic Kidney Disease
- In general, try to avoid starting tenofovir disoproxil fumarate with eGFR <60 mL/min and TAF if <30 mL/Min; avoid ATV
- Can use TAF on hemodialysis
Switching Regimens
- May be indicated to simplify regimens (single-pill), interactions, tolerability, comorbidities, pregnancy, or cost
- Goal is to maintain viral suppression to avoid resistance
- Consider:
- Previous exposure to ART
- Previous pattersn of resistance
- Likelihood of adherence
- Drug-drug and drug-food interactions
- Comorbidities
- Can switch within- or between-class
- Within-class
- EFV to RPV
- RAL to EVG or DTG
- DTG to BIC
- TDF or ABC to TAF
- Between-class
- Boosted PI to RPV
- Boosted PI to EVG, DTG, or BIC
- NNRTI to EVG or DTG
- Within-class
- TDF to TAF may see an increase in cholesterol
Side Effects
- Kidney problems
- Metabolic complications
- Osteoporosis
- Dyslipidemia
- Cardiovascular disease
References
- ^ Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. New England Journal of Medicine. 2015;373(9):795-807. doi:10.1056/nejmoa1506816.
- ^ A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa. New England Journal of Medicine. 2015;373(9):808-822. doi:10.1056/nejmoa1507198.
